Botulinum Toxin as an Adjunctive Therapy for Immobilization of a Distal Humerus Fracture in Parkinson’s Disease-Associated Psychosis: A Case Report

Patient: Female, 75-year-old Final Diagnosis: Healing fracture Symptoms: Deformity • pain Clinical Procedure: Open reduction and internal fixation of the right humerus • revision of open reduction and internal fixation of the right humerus Specialty: Orthopedics and Traumatology OBJECTIVE: Unusual clinical course BACKGROUND: Attainment of extremity immobilization in orthopedic trauma patients experiencing psychosis is often uniquely challenging. Many fractures, including those of the distal humerus, require a period of immobilization postoperatively to optimize fracture healing. Patients with Parkinson’s disease have also been shown to have lower rates of union after fracture compared to the general population. The combination of Parkinson’s disease and associated psychosis requires heightened attention to those parameters that may hinder fracture healing, such as inadequate immobilization of the fracture. Botulinum toxin has previously been described as a potential adjunctive therapy for fracture immobilization but has not yet been described in the setting of distal humerus fractures. CASE REPORT: A 75-year-old woman with Parkinson’s disease-associated psychosis presented 2 weeks after open reduction and internal fixation of a distal third humeral shaft fracture due to failure of fixation and episodes of violent hallucinations. The patient underwent irrigation and debridement, and revision open reduction and internal fixation. Given her uncontrolled hallucinations, intramuscular botulinum toxin injections were given to the right triceps, biceps, and brachialis muscles to aid in the immobilization of the right extremity and protect the surgical site during the perioperative period. The patient subsequently followed up at the clinic 3 months postoperatively with ongoing fracture healing, evidenced by bridging callous and bone formation on radiographs, as well as a return of motion to the extremity. CONCLUSIONS: Botulinum toxin may be a safe and effective adjunct for fracture immobilization in patients who are difficult to immobilize and have high fixation failure risk.